Skip to main content
PMC home page
Annals of the Rheumatic Diseases logoLink to Annals of the Rheumatic Diseases
. 2000 Dec;59(12):936–944. doi: 10.1136/ard.59.12.936

EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT)

A Pendleton, N Arden, M Dougados, M Doherty, B Bannwarth, J Bijlsma, F Cluzeau, C Cooper, P Dieppe, K Gunther, H Hauselmann, G Herrero-Beaumont, P Kaklamanis, B Leeb, M Lequesne, S Lohmander, B Mazieres, E Mola, K Pavelka, U Serni, B Swoboda, A Verbruggen, G Weseloh, I Zimmermann-Gorska
PMCID: PMC1753053  PMID: 11087696

Abstract

BACKGROUND—Osteoarthritis (OA) is the most common joint disease encountered throughout Europe. A task force for the EULAR Standing Committee for Clinical Trials met in 1998 to determine the methodological and logistical approach required for the development of evidence based guidelines for treatment of knee OA. The guidelines were restricted to cover all currently available treatments for knee OA diagnosed either clinically and/or radiographically affecting any compartment of the knee.
METHODS—The first stage was the selection of treatment modalities to be considered. The second stage comprised a search of the electronic databases Medline and Embase using a combination of subject headings and keywords. All European language publications in the form of systematic reviews, meta-analyses, randomised controlled trials, controlled trials, and observational studies were included. During stage three all the relevant studies were quality scored. The summary statistics for validated outcome measures, when available, were recorded and, where practical, the numbers needed to treat and the effect size for each treatment were calculated. In the fourth stage key clinical propositions were determined by expert consensus employing a Delphi approach. The final stage ranked these propositions according to the available evidence. A second set of propositions relating to a future research agenda was determined by expert consensus using a Delphi approach.
RESULTS—Over 2400 English language publications and 400 non-English language publications were identified. Seven hundred and forty four studies presented outcome data of the effects of specific treatments on knee OA. Quantitative analysis of treatment effect was possible in only 61 studies. Recommendations for the management of knee OA based on currently available data and expert opinion are presented. Proposals for a future research agenda are highlighted.
CONCLUSIONS—These are the first clinical guidelines on knee OA to combine an evidence based approach and a consensus approach across a wide range of treatment modalities. It is apparent that certain clinical propositions are supported by substantial research based evidence, while others are not. There is thus an urgent need for future well designed trials to consider key clinical questions.



Full Text

The Full Text of this article is available as a PDF (399.9 KB).

Figure 1  .

Figure 1  

Open in a new tab

Interventions assessed in clinical trials of knee osteoarthritis. SYSADOA = symptomatic slow acting drugs for osteoarthritis; IA HA = intra-articular hyaluronic acid; NSAID = non-steroidal anti-inflammatory drug.

Figure 2  .

Figure 2  

Open in a new tab

Overall experts' opinion of the usefulness of the different treatment modalities. Results are given as the means (SD) of the opinions of the 21 experts. VAS = visual analogue scale, in which 0 = I do not recommend this treatment modality and 100 = I strongly recommend this treatment modality; NSAIDs = non-steroidal anti-inflammatory drugs; SYSADOA = symptomatic slow acting drugs for osteoarthritis; IA = intra-articular.

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Bourgeois P., Chales G., Dehais J., Delcambre B., Kuntz J. L., Rozenberg S. Efficacy and tolerability of chondroitin sulfate 1200 mg/day vs chondroitin sulfate 3 x 400 mg/day vs placebo. Osteoarthritis Cartilage. 1998 May;6 (Suppl A):25–30. doi: 10.1016/s1063-4584(98)80008-3. [DOI] [PubMed] [Google Scholar]
  2. Bradley J. D., Brandt K. D., Katz B. P., Kalasinski L. A., Ryan S. I. Treatment of knee osteoarthritis: relationship of clinical features of joint inflammation to the response to a nonsteroidal antiinflammatory drug or pure analgesic. J Rheumatol. 1992 Dec;19(12):1950–1954. [PubMed] [Google Scholar]
  3. Bucsi L., Poór G. Efficacy and tolerability of oral chondroitin sulfate as a symptomatic slow-acting drug for osteoarthritis (SYSADOA) in the treatment of knee osteoarthritis. Osteoarthritis Cartilage. 1998 May;6 (Suppl A):31–36. doi: 10.1016/s1063-4584(98)80009-5. [DOI] [PubMed] [Google Scholar]
  4. Caine S. B., Heinrichs S. C., Coffin V. L., Koob G. F. Effects of the dopamine D-1 antagonist SCH 23390 microinjected into the accumbens, amygdala or striatum on cocaine self-administration in the rat. Brain Res. 1995 Sep 18;692(1-2):47–56. doi: 10.1016/0006-8993(95)00598-k. [DOI] [PubMed] [Google Scholar]
  5. Deal C. L., Schnitzer T. J., Lipstein E., Seibold J. R., Stevens R. M., Levy M. D., Albert D., Renold F. Treatment of arthritis with topical capsaicin: a double-blind trial. Clin Ther. 1991 May-Jun;13(3):383–395. [PubMed] [Google Scholar]
  6. Dieppe P. A., Sathapatayavongs B., Jones H. E., Bacon P. A., Ring E. F. Intra-articular steroids in osteoarthritis. Rheumatol Rehabil. 1980 Nov;19(4):212–217. doi: 10.1093/rheumatology/19.4.212. [DOI] [PubMed] [Google Scholar]
  7. Doherty M., Jones A. Design of clinical trials in knee osteoarthritis: practical issues for debate. Osteoarthritis Cartilage. 1998 Nov;6(6):371–373. doi: 10.1053/joca.1998.0139. [DOI] [PubMed] [Google Scholar]
  8. Dougados M., Nguyen M., Listrat V., Amor B. High molecular weight sodium hyaluronate (hyalectin) in osteoarthritis of the knee: a 1 year placebo-controlled trial. Osteoarthritis Cartilage. 1993 Apr;1(2):97–103. doi: 10.1016/s1063-4584(05)80024-x. [DOI] [PubMed] [Google Scholar]
  9. Downs S. H., Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998 Jun;52(6):377–384. doi: 10.1136/jech.52.6.377. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Dreiser R. L., Tisne-Camus M. DHEP plasters as a topical treatment of knee osteoarthritis--a double-blind placebo-controlled study. Drugs Exp Clin Res. 1993;19(3):117–123. [PubMed] [Google Scholar]
  11. Ettinger W. H., Jr, Burns R., Messier S. P., Applegate W., Rejeski W. J., Morgan T., Shumaker S., Berry M. J., O'Toole M., Monu J. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST). JAMA. 1997 Jan 1;277(1):25–31. [PubMed] [Google Scholar]
  12. Felson D. T., Zhang Y., Anthony J. M., Naimark A., Anderson J. J. Weight loss reduces the risk for symptomatic knee osteoarthritis in women. The Framingham Study. Ann Intern Med. 1992 Apr 1;116(7):535–539. doi: 10.7326/0003-4819-116-7-535. [DOI] [PubMed] [Google Scholar]
  13. Gaffney K., Ledingham J., Perry J. D. Intra-articular triamcinolone hexacetonide in knee osteoarthritis: factors influencing the clinical response. Ann Rheum Dis. 1995 May;54(5):379–381. doi: 10.1136/ard.54.5.379. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Gramajo R. J., Cutroneo E. J., Fernandez D. E., Gibson J. L., Cáceres Maldonado J. C., Romero F. L., Houssay R. H. A single-blind, placebo-controlled study of glycosaminoglycan-peptide complex ('Rumalon') in patients with osteoarthritis of the hip or knee. Curr Med Res Opin. 1989;11(6):366–373. doi: 10.1185/03007998909110137. [DOI] [PubMed] [Google Scholar]
  15. Guidelines for the diagnosis, investigation and management of osteoarthritis of the hip and knee. Report of a Joint Working Group of the British Society for Rheumatology and the Research Unit of the Royal College of Physicians. J R Coll Physicians Lond. 1993 Oct;27(4):391–396. [PMC free article] [PubMed] [Google Scholar]
  16. Hochberg M. C., Altman R. D., Brandt K. D., Clark B. M., Dieppe P. A., Griffin M. R., Moskowitz R. W., Schnitzer T. J. Guidelines for the medical management of osteoarthritis. Part II. Osteoarthritis of the knee. American College of Rheumatology. Arthritis Rheum. 1995 Nov;38(11):1541–1546. doi: 10.1002/art.1780381104. [DOI] [PubMed] [Google Scholar]
  17. Jones A., Doherty M. Intra-articular corticosteroids are effective in osteoarthritis but there are no clinical predictors of response. Ann Rheum Dis. 1996 Nov;55(11):829–832. doi: 10.1136/ard.55.11.829. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Jüni P., Witschi A., Bloch R., Egger M. The hazards of scoring the quality of clinical trials for meta-analysis. JAMA. 1999 Sep 15;282(11):1054–1060. doi: 10.1001/jama.282.11.1054. [DOI] [PubMed] [Google Scholar]
  19. Keefe F. J., Caldwell D. S., Baucom D., Salley A., Robinson E., Timmons K., Beaupre P., Weisberg J., Helms M. Spouse-assisted coping skills training in the management of osteoarthritic knee pain. Arthritis Care Res. 1996 Aug;9(4):279–291. doi: 10.1002/1529-0131(199608)9:4<279::aid-anr1790090413>3.0.co;2-6. [DOI] [PubMed] [Google Scholar]
  20. Knutson K., Lewold S., Robertsson O., Lidgren L. The Swedish knee arthroplasty register. A nation-wide study of 30,003 knees 1976-1992. Acta Orthop Scand. 1994 Aug;65(4):375–386. doi: 10.3109/17453679408995475. [DOI] [PubMed] [Google Scholar]
  21. Kovar P. A., Allegrante J. P., MacKenzie C. R., Peterson M. G., Gutin B., Charlson M. E. Supervised fitness walking in patients with osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med. 1992 Apr 1;116(7):529–534. doi: 10.7326/0003-4819-116-7-529. [DOI] [PubMed] [Google Scholar]
  22. Laupacis A., Sackett D. L., Roberts R. S. An assessment of clinically useful measures of the consequences of treatment. N Engl J Med. 1988 Jun 30;318(26):1728–1733. doi: 10.1056/NEJM198806303182605. [DOI] [PubMed] [Google Scholar]
  23. Lee P., Davis P., Prat A. The efficacy of diflunisal in osteoarthritis of the knee. A Canadian Multicenter Study. J Rheumatol. 1985 Jun;12(3):544–548. [PubMed] [Google Scholar]
  24. Listrat V., Ayral X., Patarnello F., Bonvarlet J. P., Simonnet J., Amor B., Dougados M. Arthroscopic evaluation of potential structure modifying activity of hyaluronan (Hyalgan) in osteoarthritis of the knee. Osteoarthritis Cartilage. 1997 May;5(3):153–160. doi: 10.1016/s1063-4584(97)80010-6. [DOI] [PubMed] [Google Scholar]
  25. Mazzuca S. A., Brandt K. D., Katz B. P., Chambers M., Byrd D., Hanna M. Effects of self-care education on the health status of inner-city patients with osteoarthritis of the knee. Arthritis Rheum. 1997 Aug;40(8):1466–1474. doi: 10.1002/art.1780400815. [DOI] [PubMed] [Google Scholar]
  26. Morreale P., Manopulo R., Galati M., Boccanera L., Saponati G., Bocchi L. Comparison of the antiinflammatory efficacy of chondroitin sulfate and diclofenac sodium in patients with knee osteoarthritis. J Rheumatol. 1996 Aug;23(8):1385–1391. [PubMed] [Google Scholar]
  27. Müller-Fassbender H., Bach G. L., Haase W., Rovati L. C., Setnikar I. Glucosamine sulfate compared to ibuprofen in osteoarthritis of the knee. Osteoarthritis Cartilage. 1994 Mar;2(1):61–69. doi: 10.1016/s1063-4584(05)80007-x. [DOI] [PubMed] [Google Scholar]
  28. Noack W., Fischer M., Förster K. K., Rovati L. C., Setnikar I. Glucosamine sulfate in osteoarthritis of the knee. Osteoarthritis Cartilage. 1994 Mar;2(1):51–59. doi: 10.1016/s1063-4584(05)80006-8. [DOI] [PubMed] [Google Scholar]
  29. O'Reilly S. C., Muir K. R., Doherty M. Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomised controlled trial. Ann Rheum Dis. 1999 Jan;58(1):15–19. doi: 10.1136/ard.58.1.15. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Pavelka K., Jr, Sedlácková M., Gatterová J., Becvár R., Pavelka K., Sr Glycosaminoglycan polysulfuric acid (GAGPS) in osteoarthritis of the knee. Osteoarthritis Cartilage. 1995 Mar;3(1):15–23. doi: 10.1016/s1063-4584(05)80034-2. [DOI] [PubMed] [Google Scholar]
  31. Pujalte J. M., Llavore E. P., Ylescupidez F. R. Double-blind clinical evaluation of oral glucosamine sulphate in the basic treatment of osteoarthrosis. Curr Med Res Opin. 1980;7(2):110–114. doi: 10.1185/03007998009112036. [DOI] [PubMed] [Google Scholar]
  32. Ravaud P., Moulinier L., Giraudeau B., Ayral X., Guerin C., Noel E., Thomas P., Fautrel B., Mazieres B., Dougados M. Effects of joint lavage and steroid injection in patients with osteoarthritis of the knee: results of a multicenter, randomized, controlled trial. Arthritis Rheum. 1999 Mar;42(3):475–482. doi: 10.1002/1529-0131(199904)42:3<475::AID-ANR12>3.0.CO;2-S. [DOI] [PubMed] [Google Scholar]
  33. Røgind H., Bibow-Nielsen B., Jensen B., Møller H. C., Frimodt-Møller H., Bliddal H. The effects of a physical training program on patients with osteoarthritis of the knees. Arch Phys Med Rehabil. 1998 Nov;79(11):1421–1427. doi: 10.1016/s0003-9993(98)90238-6. [DOI] [PubMed] [Google Scholar]
  34. Sandelin J., Harilainen A., Crone H., Hamberg P., Forsskåhl B., Tamelander G. Local NSAID gel (eltenac) in the treatment of osteoarthritis of the knee. A double blind study comparing eltenac with oral diclofenac and placebo gel. Scand J Rheumatol. 1997;26(4):287–292. doi: 10.3109/03009749709105318. [DOI] [PubMed] [Google Scholar]
  35. Sasaki T., Yasuda K. Clinical evaluation of the treatment of osteoarthritic knees using a newly designed wedged insole. Clin Orthop Relat Res. 1987 Aug;(221):181–187. [PubMed] [Google Scholar]
  36. Schilke J. M., Johnson G. O., Housh T. J., O'Dell J. R. Effects of muscle-strength training on the functional status of patients with osteoarthritis of the knee joint. Nurs Res. 1996 Mar-Apr;45(2):68–72. doi: 10.1097/00006199-199603000-00002. [DOI] [PubMed] [Google Scholar]
  37. Superio-Cabuslay E., Ward M. M., Lorig K. R. Patient education interventions in osteoarthritis and rheumatoid arthritis: a meta-analytic comparison with nonsteroidal antiinflammatory drug treatment. Arthritis Care Res. 1996 Aug;9(4):292–301. doi: 10.1002/1529-0131(199608)9:4<292::aid-anr1790090414>3.0.co;2-4. [DOI] [PubMed] [Google Scholar]
  38. Tohyama H., Yasuda K., Kaneda K. Treatment of osteoarthritis of the knee with heel wedges. Int Orthop. 1991;15(1):31–33. doi: 10.1007/BF00210530. [DOI] [PubMed] [Google Scholar]
  39. Uebelhart D., Thonar E. J., Delmas P. D., Chantraine A., Vignon E. Effects of oral chondroitin sulfate on the progression of knee osteoarthritis: a pilot study. Osteoarthritis Cartilage. 1998 May;6 (Suppl A):39–46. doi: 10.1016/s1063-4584(98)80011-3. [DOI] [PubMed] [Google Scholar]
  40. Weinberger M., Tierney W. M., Booher P., Katz B. P. Can the provision of information to patients with osteoarthritis improve functional status? A randomized, controlled trial. Arthritis Rheum. 1989 Dec;32(12):1577–1583. doi: 10.1002/anr.1780321212. [DOI] [PubMed] [Google Scholar]
  41. Williams H. J., Ward J. R., Egger M. J., Neuner R., Brooks R. H., Clegg D. O., Field E. H., Skosey J. L., Alarcón G. S., Willkens R. F. Comparison of naproxen and acetaminophen in a two-year study of treatment of osteoarthritis of the knee. Arthritis Rheum. 1993 Sep;36(9):1196–1206. doi: 10.1002/art.1780360904. [DOI] [PubMed] [Google Scholar]
  42. Willims R. A., Foulsham B. M. Weight reduction in osteoarthritis using phentermine. Practitioner. 1981 Feb;225(1352):231–232. [PubMed] [Google Scholar]
  43. Woolf S. H., Grol R., Hutchinson A., Eccles M., Grimshaw J. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999 Feb 20;318(7182):527–530. doi: 10.1136/bmj.318.7182.527. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Annals of the Rheumatic Diseases are provided here courtesy of BMJ Publishing Group

RESOURCES